Alice Hyde Medical Center

Inspectors wroteBased on observations, interviews and record review during a survey, the facility failed to ensure residents were free from abuse of any type. Specifically, (a) the facility failed to implement care planning interventions to appropriately address Resident #2 who had a documented history of sexually inappropriate behaviors. This resulted in Resident #1 being sexually assaulted by Resident #2. Using the reasonable person concept, as referenced on the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity Guide, the facility's failure to protect residents from sexual abuse resulted in psychosocial harm to Resident #1 that was not Immediate Jeopardy. (b) Resident #3 had a behavior care plan that documented they demonstrated verbally and physically abusive behavior. [...]

Inspectors wroteBased on record review and interview conducted during the survey, the facility failed to allow one (1) of three (3) residents (Resident #2) to return to the facility to their previous room or immediately upon the first availability of a bed. Specifically, Resident #2, who was on leave at the hospital, was not allowed to return to the facility despite Family Member #2 wanting Resident #2 to return to the facility when they were ready to be discharged from the hospital. Family Member #2 was informed the facility would not accept Resident #2 back and was directed to speak with the social worker/discharge planner at the hospital to assist with arranging an alternative placement. Director of Nursing #1 stated Resident #2 could not be kept on one to one (1:1) supervision after 15-minute checks for safety had failed. This is evidenced by: Cross reference: [...]

Inspectors wroteBased on observation, record review and interviews during an abbreviated survey (Case #578139, 578179, and 578120), the facility did not ensure residents were free from neglect for three (3) (Resident #s 7, 105, and 119) of seven (7) residents reviewed for neglect. Specifically, for Resident #7, the facility staff did not perform toileting activities every two (2) hours as care planned; for Resident #105, the facility staff did not use two people to transfer the resident despite being care planned for a two person assist transfer; and for Resident #119, facility staff did not put the resident's bed alarm on when they put the resident back to bed. The care plan violations led to all three residents falling. This is evidenced by: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and/or psychosocial needs for four (4) (Resident #'s 81 and 82) of 24 residents reviewed. Specifically, Resident #81's activities care plan was not person centered to meet the resident's activity needs and one to one visits were not provided as care planned; and Resident #82's Comprehensive Care Plan did not include the residents use of a lap belt and how to manage it. This is evidenced by: The policy titled Comprehensive Care Plan dated 4/2024, documented the facility would implement a person-centered care plan for each resident that met their needs; [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure that it provided an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three (3) (Resident #s17, 79 and 81) of three (3) residents reviewed for activities. Specifically, Resident #s 17, 79 and 81 were not provided with activities that met the residents' preferences and cognitive abilities. This is evidenced by: The Policy and Procedure titled; [...]

Inspectors wroteBased on observation, record review and interviews conducted during a recertification survey, the facility did not ensure residents were free from physical restraints imposed for purposes of discipline or convenience that were not required to treat the resident's medical symptoms, used for the least amount of time, and did not document ongoing re-evaluation of the need for restraints for one (1) (Resident #82) of three (3) residents reviewed for physical restraints. Specifically, Resident #82 did not have a physician's order for the use of a wheelchair lap belt restraint and there was no evidence of a quarterly assessment/evaluation being completed for its use. The is evidenced by: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification and abbreviated survey (Case #578117), the facility did not ensure residents were free from significant medication errors for one (1) (Resident #46) of seven (7) residents reviewed for significant medication errors. Specifically, Resident #46 was administered and received seven (7) medications that were ordered for another resident. This is evidenced by: Resident #46 The policy titled Medication Administration dated 6/2023, documented under supportive data: A.) the medication nurse was personally responsible for every drug they administered; B.) positively identified the resident before administering drugs with instruction to check the resident's identification and ask the resident to state their name and if unable to identify self, ask staff to identify the resident; [...]

Inspectors wroteBased on record reviews and interviews during an abbreviated survey (Case #NY00369068), the facility did not ensure 1 (Resident #1) of 3 residents reviewed were free from verbal abuse. Specifically, Resident #1 was not protected from verbal abuse by staff members. This is evidenced by: The policy and procedure titled Abuse Prevention and Reporting, dated 6/2023, documented the facility would not permit verbal, mental, sexual, or physical abuse. Resident #1 was admitted to the facility with the diagnoses of dementia, emphysema (a chronic lung disease that progressively damages the aveoli, or tiny air sac, in the lungs), and atrial fibrillation (irregular heart rate). The Minimum Data Set (an assessment tool) dated 12/02/2024 documented the resident could understand, be understood by others, and was cognitively intact. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #NY00334727), the facility did not ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency for 1 (Resident #20) of 4 residents reviewed for abuse. Specifically, Resident #20 was left unattended on 2/29/2024 at 12:25 PM, fell, and sustained injury while ambulating. Resident #20's care plan documented the resident required a staff member assist with transfers and ambulation. The incident was not reported to the Department of Health until 3/01/2024 at 2:18 PM. This is evidenced by: [...]

Inspectors wroteBased on observations, record review and interviews during an abbreviated survey (Case #s NY00301319, NY00313776, NY00318247, NY00318964, and #NY00324492) dated 3/18/2024 through 3/29/2024, the facility did not ensure the facility implemented a comprehensive person-centered care plan for each resident for 5 (Residents #6, 15, 19, 23, and 24) of 25 residents reviewed for comprehensive care plans. Specifically, for Residents #6, 15, and 19, 15-minute safety checks were not completed; Resident #23's bed was not in a low position and appropriate footwear was on the resident on 8/26/2022; and Resident #24's, bed alarm was not in place before the resident was put to bed on 6/11/2023 as per resident care plans. This is evidenced as follows: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #NY00324492), the facility did not ensure the resident's environment remained as free of accident hazards as was possible for 1 (Resident #15) of 5 residents reviewed for accidents. Specifically, Resident #15 was found on the floor on 9/19/2023, bed was not in a low position, call light not within reach, and resident had no socks on. This is evidenced as follows: Resident #15 Resident #15 was admitted to the facility with diagnoses of heart failure, type 2 diabetes mellitus, and end stage renal disease. The Minimum Data Set (an assessment tool) dated 9/22/2023, documented the resident could be understood and could usually understand others with a Brief Interview of Mental Status indicated moderate cognition impairment. [...]

Inspectors wroteBased on record review and interviews during the recertification survey dated 08/14/22 through 08/18/2022, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination for two (2) of 3 resident's reviewed. Specifically, the facility did not ensure that Residents #470 and #60, who received Medicare Part A services, received timely notification (2-day notification) of the termination of services with the required form Notice of Medicare Non-Coverage, Form CMS 10123-NOMNC. This is evidenced as follows: [...]

Inspectors wroteBased on observation and interviews during the recertification survey dated 08/14/22 through 08/18/22, the facility did not ensure food was prepared in accordance with professional standards for food service safety in the main kitchen, one (1) of 3 Country Kitchens, and 4 of 6 Activities Kitchens (unit kitchens). Food preparation and serving areas and equipment are to be kept clean, product thermometers are to be calibrated, and kitchen equipment is to be kept in good repair. Specifically, in the main kitchen, one food product thermometer was not in calibration; on the second floor County Kitchen, the electronic thermometer display on the [NAME] dishwashing machine was not functioning; and the refrigerators and floors in the 1-East, 1-West, 2-East, and 2-West Activities Kitchens required cleaning. This is evidenced as follows: [...]

Inspectors wroteBased on observation, interview and record review during a recertification survey, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections determined for 3 (Resident #'s 50, 63 and #223) of 3 residents reviewed on the third floor. Specifically, for Resident #50, the facility did not ensure standard precautions were maintained during a dressing change, for Resident #'s 50 and 63, the facility did not prevent the development of facility acquired pseudomonas infections (type of germ that can cause infections in humans) in their wounds and for Resident #223, standard precautions were not followed during administration of an intravenous medication. [...]

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure the resident representative was informed when there was a need to alter treatment significantly for 1 (Resident #108) of 1 resident reviewed for notification of change. Specifically, the facility did not ensure the resident representative was notified of medication changes involving psychotropic medications, due to an increase in behaviors. This was evidenced by: The Policy and Procedure (P&P) titled Family Notification, last reviewed 9/2019, documented families who were on the contact list for the resident and who may receive protected health information (PHI) would be made aware of medication changes, involving psychotropic and emergent medications. Resident #108: The resident was admitted to the facility with the diagnoses of dementia, mood disorder, and anxiety. [...]

Inspectors wroteBased on record review and interviews during a recertification survey the facility did not ensure that allegations of abuse, neglect, exploitation, or mistreatment had evidence that all alleged violations were thoroughly investigated for one (Resident #25) of 2 residents reviewed for abuse. Specifically, for Resident #25, the facility did not ensure the resident's allegation that a staff member was rough with him/her was throughly investigated. This is evidenced by: A Policy and Procedure (P&P) titled, Abuse Prevention and Reporting last reviewed 10/2019 documented any employee of the facility had a duty to report concerns, incidents including that of alleged abuse, mistreatment or neglect to their supervisor or to the Director of Nursing, Administrator, or Charge Nurse. [...]

Inspectors wroteBased on record review and interview during a recertification survey and an abbreviated survey (Case #NY00245774), the facility did not ensure each resident received adequate supervision to prevent an elopement for 1 (Resident #105) of 1 resident reviewed for accidents and supervision. Specifically, for Resident #105, the facility did not ensure the resident, who was a known risk to wander and wore a wandergard, did not elope from the building undetected until she was seen outside at the employee entrance door asking to come back into the facility because she was cold. This is evidenced by: While wander, door, or building alarms can help to monitor a resident's activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision, and require scheduled maintenance and testing to ensure proper functioning. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly Medication Regimen Review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, the facility did not ensure that time frames were established for the steps in the MRR process. This is evidenced by: The Policy for Medication Regimen Review with a revised date of 12/2019, documented: 1. The Pharmacist is to report any identified irregularities to the attending physician and Director of Nursing. 2. If any urgent issues arise, a phone call will be made directly to the Director of Nursing from the Pharmacist. 3. [...]

Inspectors wroteBased on record review and interview the facility did not provide a complete Facility Assessment that documented a facility wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies during the recertification survey. Specifically, the facility did not ensure the facility assessment included an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's needs. This is evidenced by: [...]